[Intl_DxMedPhys] Requirement for dose monitoring

Tue Aug 11 15:44:46 EDT 2026

Stephanie, it is not totally gone.  The requirement appears to be gone from the Hospital program, but it is still present in the Ambulatory Health Care and Office-Based Surgery programs.  This is from the publicly-accessible standards, https://urldefense.com/v3/__https://publicstandards.tools.jointcommission.org/__;!!KGKeukY!0SJv0VVpr4Jn-NbWMAF-Xt0_kgD-g6-mTkBbqAvwBygURwHv8U9XrDQ7FdD7o1G4J5XVTjLOkxsHm2SVpOHyyh8beUJQ0Uhm7X4hq9HPgpwtStXHRQ$ 
Choose the Program from the dropdown, and then do a keyword search to find these requirements.  I wonder what the rationale was for removing these for the Hospital program.

PC.01.02.15 The organization provides for diagnostic testing.
Chapter: Provision of Care, Treatment, and Services
Introduction: N/A
Rationale: N/A
Elements of Performance:
13. For organizations that provide fluoroscopic services: The cumulative-air kerma or kerma-area product is documented in a retrievable format. For fluoroscopy equipment that cannot display or provide cumulative-air kerma or kerma-area product, fluoroscopy time and number of images acquired are documented in a retrievable format, such as a picture archiving and communication system. Note: This element of performance does not apply to fluoroscopy equipment used for therapeutic radiation treatment planning or delivery or fluoroscopy equipment classified as a mini C-arm.

PC.02.01.01The organization provides care, treatment, or services for each patient.
Chapter: Provision of Care, Treatment, and Services
Introduction: N/A
Rationale: N/A
Elements of Performance:
30. For organizations that provide fluoroscopic services: The organization identifies radiation exposure and skin dose threshold levels that, if exceeded, trigger further review and/or patient evaluation to assess for adverse radiation effects. Note 1: Information on radiation exposure thresholds can be found in the National Council on Radiation Protection's (NCRP) report number 168 and on the US Food and Drug Administration’s (FDA) Center for Devices for Radiological Health (CDRH) website. Note 2: Radiation exposure thresholds may be established based on metrics such as reference-air kerma, cumulative-air kerma, kerma-area product, or fluoroscopy time.

Eric Gingold, MS PhD DABR FAAPM FACR

Associate Professor, Chief of Medical Physics

Department of Radiology

Thomas Jefferson University

132 S. 10th Street, Philadelphia, PA 19107

(215) 955-4315
<https://urldefense.com/v3/__http://jeffersonhealth.org/__;!!KGKeukY!0SJv0VVpr4Jn-NbWMAF-Xt0_kgD-g6-mTkBbqAvwBygURwHv8U9XrDQ7FdD7o1G4J5XVTjLOkxsHm2SVpOHyyh8beUJQ0Uhm7X4hq9HPgpzhyGIlgA$ >

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From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+eric.gingold=jefferson.edu at lists.osu.edu> on behalf of Stephanie M. Leon via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu>
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Subject: Re: [Intl_DxMedPhys] Requirement for dose monitoring

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Thanks to all who responded already! I was not imagining that there used to be a relevant TJC requirement. However, it is gone now. Stephanie M. Leon, PhD, DABR, DABSNM Chief of Diagnostic Medical Physics Associate Professor of Radiology Tel

Thanks to all who responded already! I was not imagining that there used to be a relevant TJC requirement. However, it is gone now.

Stephanie M. Leon, PhD, DABR, DABSNM

Chief of Diagnostic Medical Physics

Associate Professor of Radiology

Tel (603) 650-3796
Dartmouth-Health.org

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From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu> On Behalf Of Stephanie M. Leon via Intl_dxmedphys_wd_osu_list
Sent: Tuesday, August 11, 2026 2:42 PM
To: intl_dxmedphys_wd_osu_list at lists.osu.edu
Subject: [Intl_DxMedPhys] Requirement for dose monitoring **EXTERNAL**

Hi all, I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt out of our dose monitoring

Hi all,

I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt out of our dose monitoring program, and I am looking for any accreditation-related reason why they can’t (our state regs do not require it).

Stephanie M. Leon, PhD, DABR, DABSNM

Chief of Diagnostic Medical Physics

Associate Professor of Radiology

Tel (603) 650-3796
Dartmouth-Health.org

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